Online Health Chat with Dr. Leila Khan, MD and Susan Williams, MD

March 29, 2012


Cleveland_Clinic_Host: Abnormal calcium-related disorders such as kidney stones, hypocalcemia, Vitamin D deficiency, hyperparathyroidism, and osteoporosis can have devastating effects on your health and well-being. Diagnosis and treatment are key to managing these conditions, and will help to control symptoms and decrease the risk of other related complex problems. Join endocrinologist Dr. Leila Khan and internist Dr. Susan Williams online for answers to your questions concerning calcium metabolism disorders, symptoms, and medical treatment options.

Cleveland Clinic is a national leader in caring for patients with all types of calcium metabolism related disorders, from the routine to the complex. In our newly opened Endocrine Calcium Clinic, patients benefit from access to a multidisciplinary staff, the most advanced technology and streamlined evaluation and treatment of calcium conditions.

Dr. Khan is a specialist in the Endocrine Calcium Clinic, and a staff physician in the Endocrinology & Metabolism Institute. She is board-certified in Internal Medicine and Endocrinology, Diabetes & Metabolism. She graduated from medical school in 2004 from the University of Maryland, completed internal medicine residency and chief residency at Hershey Medical Center, and went on to complete her fellowship in endocrinology at the University of Pittsburgh. Dr. Khan’s specialty interests include diabetes, hypercalcemia, osteopenia, parathyroid and calcium disorders and Vitamin D deficiency.

Dr. Williams is a specialist in the Endocrine Calcium Clinic, and a staff physician in the Medicine Institute. She is board-certified in internal medicine, nutrition, obesity medicine, nutrition support, and bone densitometry. Dr. Williams obtained her master’s degree from the University of Rhode Island in human and clinical nutrition. She completed the U.S. Air Force internship in clinical nutrition, and served as an officer, nutrition professional, and reservist in the U.S. Air Force. She later went on to attend medical school at the Wright State University School of Medicine, residency in the Kettering Medical Center Network, and a fellowship in clinical nutrition and metabolism at the Cleveland Clinic. Dr. Williams’ specialty interests include bone and mineral metabolism, metabolic bone disease, calcium disorders, malabsorption and malnutrition in adults, and medical bariatrics.

Cleveland_Clinic_Host: To make an appointment with one of our Endocrine Calcium Clinic specialists at Cleveland Clinic, please call 216.444.6568 or call toll-free at 800.223.2273, ext. 46568. You can also visit us online at

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic doctors Leila Khan, MD and Susan Williams, MD. We are thrilled to have them here today for this chat. Let’s begin with some of your questions.

Calcium Levels and Testing

gretta: My mother had a thyroidectomy recently. Since then her calcium levels have been low. She was put on calcium supplements and vitamin D tabs that have no worked so well. They are going to be changing them to try and help with regulation. If they can’t get this regulated, what can happen? Also, is there anything she can do at home (diet, supplements, etc.) that can also help or even hurt?

Dr__Khan: It is important to work closely with her doctors to try to get a good regimen for calcium treatment. This can often include vitamin D replacement in active form called calcitriol and calcium replacement. It can be challenging to get levels perfect right away but usually with a few different combinations, one can eventually get on the right dosages. It is important to see an endocrinologist to help manage this if you are not yet seeing one yet. Measuring calcium in urine is also an important part of the treatment of hypocalcemia. Lastly, I would not encourage any supplement without discussion with physician, because it may be harmful.

Debbie284: I have several out of range ionized calcium testing, a positive sestamibi scan for an adenoma, but my serum calcium levels are never out of range, only at the top of the range from time to time, and normal PTH levels. I had an LH/FSH pituitary tumor removed about 10 years ago would this affect my calcium testing?

Dr__Khan: The pituitary tumor should not affect the calcium levels. On occasion, due to protein binding abnormalities, the ionized level can be abnormal while the blood calcium okay. I would ask that you be evaluated, however, because more information is needed to determine whether you have underlying hyperparathyroidism or not. The sestamibi scan is not sensitive enough to determine what is going on.

eyes_forward: I am lactose-intolerant and have a hard time taking pills. Are there other foods I can substitute to get enough calcium? What would happen if I didn’t substitute dairy products in my diet? Will I absolutely get osteoporosis?

Dr__Williams: Other foods that can be substituted include dark leafy greens, and fortified foods such as breakfast cereals and juices (just watch the calories). Lactose intolerance is very common and prevents many adults from being able to tolerate milk. Despite the lactose intolerance, usually all dairy products don't have to be avoided. Yogurt that has live cultures in it has very low levels of lactose. Similarly, aged cheeses have little or no lactose. Finally, there are several chewable calcium supplements on the market. My personal favorite is Citracal® brand gummies. They are very easy to take, provide an easily-absorbed form of calcium that does not have to be taken with meals, and they taste great.

gena: Will my calcium levels drop significantly if I eat less calcium?

Dr__Williams: Gena, you ask a very important and popular question. The calcium that is measured in your blood actually can come from your diet and can also come from your bones. Let me explain a bit further. Our bodies are designed to maintain a fairly constant calcium level, because calcium is not only important for our bones but also muscle function and even our heartbeat. So, if a person does not consume adequate calcium in their diet, the body will take some calcium from the bones in order to keep the blood calcium normal. Your blood calcium level is unlikely to drop significantly if you eat less calcium, but your body will take calcium from your bones.

Bone Density

green_screen: How can I find out if I have weak bones? Is there a test that can help with this?

Dr__Khan: Weak bones can be assessed with a bone density evaluation and with a battery of lab tests. In addition, it is important to get a good past medical and family history. Seeing a physician for this evaluation is critical. Several people are available in Cleveland Clinic's calcium clinic if you are interested. Hope this helps!

clara: I was on Fosomax® for 13 years. I went off of it around 3 years ago. I had a bone scan last year, and it had changed a little. My T-score spine was -2.2, T-score for hip was 2.5, T-score for femur -2.7. I was put on Evista® last year. I don't know if I should go back on one of the drugs. I read that Forteo® is the drug that will build bone. Would I be able to take this drug? Also my parathyroid is 79.3 and calcium is 9.5. It was 10 a year before. My D level is around 65 - I take D. Would it benefit me to come to CC?

Dr__Williams: Clara, thank you for such an excellent question! First, the fact that your bone density has changed little is actually a good thing -- the goal of a medication such as Fosamax® is to strengthen your bones and that can't always be measured by the bone density. Second and perhaps more importantly, I would recommend that you have the elevated PTH evaluated by one of us in the Endocrine Calcium Clinic. I would be glad to see you.

europa: I have been taking estrogen for about 8 years, plus calcium. For the past year, I took calcitonin also and still had bone loss. Recently I started on Fosomax®. With all this, I am discouraged about continued loss. What else can I do besides exercise?

Dr__Khan: It is important to have the bone density checks done on the same machine since it is impossible to compare bone densities from different machines. There is something called the least significant change which means that tests that show mild decreases in density that may not be too meaningful or significant, and rather reflect the accuracy of machine. Lastly, even if bone density has decreased, if you have not had bone fractures, this is quite reassuring. If density continues to decrease, you may need an alternative agent that is given in intravenous form or subcutaneous form. In addition to exercise, it is important to take in at least 1200 mg calcium and make sure your vitamin D level is at least 30 mg/dL too. Hope this helps!

you_and_me: My bone density test results are worse this time but I'm taking my Fosamax®. How can that happen?

Dr__Khan: That being said, if density is truly decreasing, this needs to be further evaluated by a physician to determine whether you are absorbing medication. Perhaps you need an intravenous form. An evaluation can determine whether calcium and D intake is good enough, or if there is another thing going on. Please discuss with your doctor. The goal is to maintain bone density if possible. Although value may be lower, it depends on magnitude of decrease. There is something called a least significant change which a number dependent on each bone density machine and means that despite a lower number, density is actually stable.

stark: What types of things would cause me to have a higher chance of getting osteoporosis?

Dr__Khan: Please talk with your physician to see if you have any risk factors. Several things can worsen osteoporosis including premature menopause, a diet low in calcium or vitamin D, and medications including steroids, blood thinners, and seizure medications. Risk factors also include untreated celiac disease, low exercise, and untreated hyperparathyroidism. Hope this helps!

Vitamin D

jellyb: My vitamin D was found to be low, so I began taking a supplement for a few weeks. After awhile I stopped. Is that bad?

Dr__Williams: Low vitamin D is very common these days, but how to treat it and how long to treat it is still somewhat open for debate. Vitamin D deficiency can usually be easily treated with a supplement. Some physicians choose to recommend a higher dose that can be taken once weekly while others will recommend a lower dose to be taken daily. Both ways are effective in correcting the low D level. But often times, if the D was truly low, it will become low again if the supplement is stopped. My recommendation is to have your D level tested again, talk with your doctor, and see what dose of D is most beneficial for you. You are also welcome to come see us at the Endocrine Calcium Clinic and we'd be glad to lend a hand.

a_team: Are there upper limits to how much vitamin D you should take? What is a maximum? My blood level of vitamin D is very low.

Dr__Khan: At this time, it is unclear what the ideal level of Vitamin D should be for most individuals. Usually, I strive to get a value between the 30-40 range. Higher numbers can also be okay, but a low number is concerning since it can result in bone loss.

Kevin: How does a doctor determine how much vitamin D a person with a deficiency should take? I’ve talked to some of my friends and they had similar low levels, but each was given a different treatment plan. How does a doctor determine which is best?

Dr__Khan: There are several different ways to increase D values and each is generally not better than another. It depends on magnitude of deficiency but sometimes people get the high dose treatment (50,000 IU) to take monthly or weekly, other times people are encouraged to get a daily replacement for 2,000 to 4,000 IU. The key is making sure that level is followed up on so that a low level is corrected. It can take several months to do this. Hope this helps!

Dr__Williams: Excellent question. Dr. Khan already answered this, but I wanted to add my bit as well. A simple blood test ordered by your doctor for something called "25-hydroxyvitamin D" can rapidly determine your D level.

zual: Not having current health issues and approaching my 50th birthday. What proactive steps may be taken to get enough vitamin D and calcium?

Dr__Williams: Happy early 50th Birthday Zual! There is a lot you can do proactively as there is simply no substitute for good nutrition and lifestyle choices. Getting adequate calcium and vitamin D throughout your lifetime is important for bone health. Avoiding excess alcohol and not smoking are two vitally important choices as well. Attaining and maintaining normal body weight is important. And finally, getting routine physical activity will help maintain healthy bones as well as keep your muscles strong. Keeping your muscles strong will prevent falls, and if we can prevent falls, we can often prevent broken bones.


on_ice: What is hyperparathyroidism? Is it related to the thyroid?

Dr__Khan: Hyperparathyroidism is a condition where the parathyroid level is inappropriate. There can be a primary cause for this (where surgery is typically the answer) or several secondary causes including vitamin D deficiency, kidney disease, low calcium intake, etc. Tertiary hyperparathyroidism exists as well. This condition is unrelated to thyroid. If you do have primary hyperparathyroidism, this is a very treatable condition. You can involve a specialized surgeon to help with treatment. Medicine is also available.

momma_mia: How common is hyperparathyroidism in younger individuals? My daughter is 14 and experiencing a lot of the symptoms. Should I have her checked out?

Dr__Khan: If you are concerned about hyperparathyroidism, please discuss with your daughter's doctor. Testing involves simple blood tests including PTH, calcium, albumin, vitamin D. Good luck!

honor_system: I was recently diagnosed with high calcium levels. I have a follow up appointment in a few weeks, but can you tell me what this means and whether I need to be concerned?

Dr__Khan: High calcium levels need to be evaluated. Often, if you have a high value for years, this may represent hyperparathyroidism (primary). Be careful about how much vitamin D you are taking and consider stopping HCTZ medication for blood pressure too, because these can result in higher calcium values. And certainly stay off the calcium supplements including Tums®!

mamabear: My son’s doctor at the University of Michigan wants to keep calcium low because he is at high risk for the surgery for hyperparathyroidism.

Dr__Williams: You raise a very important point. When treating hyperparathyroidism, often times the blood calcium can become quite high. This is very different from preventing or treating osteoporosis and the physician, such as in the case of your son, will recommend keeping the calcium lower.

PENN: I have had bariatric surgery at Robert Wood Johnson Hospital and at Cleveland Clinic in 2006. I have high calcium and PTH levels and low D2. I recently had rotator cuff surgery and lost my rotator cuff due to thin muscle. A doctor who gave me a nerve block before surgery in looking over my chart asked me if I had hyperparathyroidism. Am I at risk for this disease? When is this surgery done to help patients? What are the risks of surgery?

Dr__Khan: Bariatric surgery makes one prone for vitamin D deficiency and this can cause hyperparathyroidism (secondary) due to vitamin deficiencies. It is important to work with your doctor to have this treated since hyperparathyroidism is not good for your bones. You likely do not need parathyroid surgery but will need to start right dosing of D replacement. Hope this helps!

Debbie284: What testing would be needed to determine hyperparathyroidism?

Dr__Khan: Further testing for hyperparathyroidism would likely include blood work, bone density, urine collections, etc.

Additional Question

PENN: I get so tired when doing very little. After a short shopping trip, I can barely make it back to my car and have to sit a while before I can drive home. I can only do short house cleaning. I ache all over and now have pitting edema at my left ankle. I was told that the bariatric surgery I had was the reason my rotator cuff was too thin to repair. Is there a way to regain my muscle bulk? I had more severe bariatric surgery at the Clinic and still did not lose weight. I still weigh around 289 lbs. Is there any help for my symptoms? Is there help for my fatigue and aching?

Dr__Khan: Dear Penn - given your history of bariatric surgery, I would be sure that you do not have a vitamin deficiency such as D deficit. I would recommend seeing Dr. Susan Williams, a specialist in this area, who can evaluate you further. Hope this helps!

Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic specialists Dr. Leila Khan and Dr. Susan Williams is now over. Thank you both for taking the time to answer our questions today about Calcium Metabolism Disorders: Causes, Symptoms and Treatments.

Dr__Khan: Thank you all for chatting with us today. We are very sorry about the delay. Thanks for all your patience!

Dr__Williams: Again, sorry about the delay. We will try to answer some of the questions that we did not get to and these will be posted in the chat transcripts, so please check back!

More Information

To make an appointment with one of our Endocrine Calcium Clinic specialists at Cleveland Clinic, please call 216.444.6568 or call toll-free at 800.223.2273, ext. 46568. You can also visit us online at

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